Ineffective multi-agency working and a service restructuring meant opportunities to intervene were missed in the case of a woman with schizophrenia who died of malnutrition.
A safeguarding adults review (SAR) in Plymouth found that mental health services involved with Ruth Mitchell, who died aged 40, had a “culture of avoiding consulting with the [local] adult safeguarding team”.
Mitchell, who had been known to mental health services since 1996 and had alcohol and self-neglect problems, was found dead at her home in September 2012. She had been stepped down from an enhanced care programme approach (CPA) to a less formal ‘standard care’ pathway in 2007 – shortly after her parents complained about the level of support being offered to her.
The SAR said Mitchell was “clear that she did not want the intrusion of mental health services in her life”, though she continued to see professionals sporadically during her last five years.
It found that mental health services, wary of her disengaging entirely, made little attempt at “further relationship building”. This meant the possibilities of other agencies supporting her under their guidance went unexplored.
Since the Care Act 2014 was not in place during the period considered by the review, self-neglect was not included in adult safeguarding arrangements. However, in 2006 Plymouth had been one of the first local authorities in the UK to implement a procedure to address self-neglect, the Vulnerable Adults Risk Management Meeting process (VARMM).
Following Mitchell’s discharge from CPA, fears for her welfare were raised on a number of occasions but were seldom shared between agencies.
Her neighbour phoned the police in April 2008 worried that he had not heard from her in two days. On that occasion the police attended and found her asleep but recorded her “safe and well” and did not inform mental health services.
The following year, psychiatrists who saw her noted that she was “not very good” at engaging with services and had an “unrealistic view” of her abilities. They decided to discuss potentially allocating her other support but, the SAR found, there was no evidence as to whether this ever happened. In 2010, another consultant expressed concern at how isolated she was but found that she seemed stable, a perception shared by a number of the doctors who saw her during outpatient appointments.
In December 2010 Mitchell’s neighbour again called the police as he had not seen her. She was found surrounded by medication and “curled in a ball” in her home, which was sparsely furnished and unheated since her housing provider, unaware of her vulnerabilities, had capped off the gas in 2008. But, as she denied taking an overdose and said she “felt well in herself”, she was left at home.
The SAR said it was “unclear” why Mitchell was not escalated back to CPA after this incident, and queried why a mental capacity assessment had not been considered. “Those interviewed as part of this SAR have reported that the provisions of the mental capacity act were not well understood in the mental health teams,” it said.
The ambulance team that attended Mitchell’s home apparently made a referral to adult social care, also requesting a mental health review and heating for the flat, but no record of this being received was found.
While another psychiatrist who saw Mitchell in 2011 assessed her situation as having “minimal” risk, commenting that her “isolated lifestyle helped her to feel more in control”, her parents’ concerns about her wellbeing continued. Her father commented that she had “declined dramatically” when they saw her – for the last time – in December that year.
Mental health services made no follow-up visits to her, however, nor was she seen again by them except for one planned appointment in February 2012. While police again forced entry to her flat in June 2012 after a call from the neighbour, there is no evidence of mental health services being informed.
The review found opportunities were missed, in December 2010 and 2011, to refer Mitchell for consideration under Plymouth’s VARMM procedures.
These had been designed for adults who were self-neglecting and refusing services, and included facilitating a mental capacity assessment and a ‘networked’ approach via which the agency best placed to successfully re-engage would take a lead. The VARMM procedures could have allowed for “creative interventions”, the review said.
But it found that the process, which was local authority-led, was poorly understood within the NHS-led mental health partnership, and little used. Meanwhile, more knowledgeable adult care team managers working within the partnership were not responsible for day-to-day case supervision, meaning they were likely to have been out of the loop.
“Both the adult care safeguarding lead and the primary care trust safeguarding lead state that VARMM was used extensively until 2009, when a review and restructure of adult social care was initiated,” the review said. “A culture of ‘avoiding’ VARMM and in doing so, avoiding consulting with the adult safeguarding team, arose.”
Governance arrangements within the mental health partnership, the SAR found, were “uncertain”. For unknown reasons, a psychiatric nurse responsible for liaising with Mitchell’s family retained her status as a point of contact despite being moved to a different area team in 2009. The wider picture was further complicated by ongoing restructuring of mental health services during 2011 and 2012.
“Ruth appears to have been at her most vulnerable at a time of organisational change in mental health services,” the review said. “It would appear that all staff had heavy workloads; the predicament of a woman on standard care, who had been known for many years, may not have [had] the attention it needed.”
‘Working very separately’
The SAR concluded that agencies involved with Mitchell had “worked very separately and shared no information”.
Among a series of key learning points, the review said that agencies needed to share information more effectively, follow multi-agency safeguarding and risk management guidance, improve record-keeping and referral follow-up, and promote better contact with people at risk of self-neglect.
Steve Waite, the chief executive of Livewell Southwest, which now delivers mental health and adult social care services in Plymouth, said that “significant changes” had already been implemented.
“There were missed opportunities in Ruth’s care and information was not shared when it should have been,” he said. “While nothing can bring Ruth back, we have come a long way in the last five years – the police, housing, the council and community groups work really well with us today to ensure that people at risk of self-neglect, and their families, can get the care and support they need.”